Positive Behavior & Intervention System Parental Request for Assistance
Parents,
This request for assistance form is for parents & families to reach out when in need of help to manage their child's behavior in school. This program is for students that have been sent to in-school suspension (GASP), out-of-school suspensions, repeated referrals to the office staff of W.T. Lewis for disciplinary reasons, & concerns for social & emotional development for students. Any information submitted is confidential & will be shared with PBIS Committee members only.

This request is not a request for a teacher conference, nor a request for counseling. If a teacher conference is needed, please contact the teacher directly. If a counseling session is needed, please call Miss Williams at 759-2108.

Thank you,
PBIS Committee

Student's Name *
Your answer
Grade *
Homeroom Teacher *
Your answer
Parent Name *
Your answer
Parent Contact Phone # *
Your answer
What is your primary concern? *
Your answer
Please select any classes that your child is not passing. (grades of D or F) *
Required
Please select any external behaviors that you have seen your child display or that a teacher has reported to you. *
Required
Please select any internal behaviors that you have seen your child display or that a teacher has reported to you. *
Required
Please select any contributing factors that you feel have led to your child displaying any of the above behaviors. *
Required
Please add any additional information that you feel would be important for the PBIS Committee to know.
Your answer
Submit
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